Medical record keeping as interactional accomplishment
Søren Beck Nielsen | Copenhagen University
Medical records are documents of tremendous social importance. They have been the subject of much medical and sociological research, in particular regarding validity, accessibility and readability. This paper uses Conversation Analysis to add an aspect to the understanding of medical records that has been missing so far, namely how medical records are produced as interactional accomplishments; specifically, how hospital staff members during meetings conversationally negotiate and reach conclusions, treatment recommendations, and other types of consequential decisions. The process involves four steps: assessing patients, interpreting implications, drawing conclusions, and dictating conclusions on tape. The key finding is that participants throughout the process orient towards a need for consensus, whilst at the same time acknowledging the doctors’ interactional leading roles. This insight can enhance our understanding of medical records in hospital settings as constructed and negotiated realities.
Keywords: health care communication, geriatrics, ethnomethodology, Conversation Analysis, dictation, medical records, decision-making, co-authorship, multidisciplinarity, interactional leadership
Published online: 25 August 2014
https://doi.org/10.1075/ps.5.2.03nie
https://doi.org/10.1075/ps.5.2.03nie
References
Antaki, Charles, Barnes, Rebecca, and Leudar, Ivan
2005 Diagnostic Formulations in Psychotherapy. Discourse Studies 7, 6: 627–647. 
Atkinson, Maxwell J. and Heritage, John
(eds) 1984 Structures of Social Action. Studies in Conversation Analysis. Cambridge: Cambridge University Press.
Beck Nielsen, Søren
2009 Accounts on the Behalf of Patients During Geriatric Case Conferences. Research on Language and Social Interaction 42, 3: 231–248.
Berg, Marc
1996 Practices of Reading and Writing. The Constitutive Role of the Patient Record in Medical Work. Sociology of Health and Illness 18, 4: 499–524.
Berg, Marc and Winthereik, Britt Ross
2004 Waiting for Godot: Episodes from the History of Patient Records. In: Health Information Management, Integrating Information Technology in Health Care Work, Marc Berg (ed), 11–44. London: Routledge.
Boockvar, Kenneth S., Livote, E.E., Goldstein, N., Nebeker, J.R., Siu, A. and Fried, T
2010 Electronic Health Records and Adverse Drug Events after Patient Transfer. Quality & Safety in Health Care 19, 5: 1–5.
Brown, Penelope and Levinson, Stephen C
1987 Politeness: Some Universals in Language Usage. Cambridge: Cambridge University Press.
Bucholtz, Mary
2000 The Politics of Transcription. Journal of Pragmatics 32, 10: 1439–1465.
Collins, Sarah, Drew, Paul, Watt, Ian S. & Entwistle, Vikki A
2000 ‘Unilateral’ and ‘bilateral’ practitioner approaches in decision-making about treatment. Social Science & Medicine 61, 12: 2611–2627.
David, Gary C., Garcia, Angela Cora, Rawls, Anne Warfield & Chand, Donald
2009 Listening to what is said – transcribing what is heard: the impact of speech recognition technology (SRT) on the practice of medical transcription (MT). Sociology of Health & Illness 31, 6: 924–938.
Garcia, Angela Cora, David, Gary C. & Chand, Donald
2010 Understanding the work of medical transcriptionists in the production of medical records. Health Informatics Journal 16, 2: 87–100.
Garfinkel, Harold
1967 Studies in Ethnomethodology. Englewood Cliffs, NJ: Prentice-Hall.
Goffman, Erving
1981 Footing. In: Forms of Talk, 124–159. Philadelphia: University of Pennsylvania Press.
Greenhalgh, Trisha, Potts, Henry W.W., Wong, Geoff, Bark, Pippa, Swinglehurst, Deborah
2009 Tension and Paradoxes in Electronic Patient Record Research. A Systematic Literature Review Using the Meta-narrative Method. Milbank Quarterly 87, 4: 729–788.
Hak, Tony
1992 Psychiatric Records as Transformations of Other Texts. In: Text in Context: Contributions to Ethnomethodology, Graham Watson and Robert M. Seiler (eds), 138–155. London: SAGE.
Heath, Christian
1982 Preserving the Consultation: Medical Record Cards and Professional Conduct. Sociology of Health & Illness 4, 1: 56–74.
1986 Body Movement and Speech in Medical Interaction. Cambridge:
Cambridge University Press.
Heath, Christian and Luff, Paul
1996 Documents and Professional Practice: ‘Bad’ Organisational Reasons for ‘Good’ Clinical Records.
Proceedings of the Conference on Computer Supported Cooperative Work
, Boston, 354–363. ACM Press.
2000 Technology in Action. Learning in Doing: Social, Cognitive, and Computational Perspectives. Cambridge: Cambridge University Press.
Heritage, John and Watson, David R
1980 Aspects of the Properties of Formulations. Semiotica 30, 3/4: 245–262.
Heritage, John and Maynard, Douglas W
(eds) 2006 Communication in Medical Care. Interaction Between Primary Care Physicians and Patients. Cambridge: Cambridge University Press.
Hoursley, William
2000 Category work and knowledgeability within multidisciplinary team meetings. Text 20, 1: 83–107.
Komter, Martha L
2006 From talk to Text: The Interactional Construction of a Police Record. Research on Language and Social Interaction, 39, 3: 201–228.
Linell, Per
1998 Approaching Dialogue. Talk, interaction and contexts in dialogical perspectives. Amsterdam: John Benjamins.
Lisby, Marianne, Nielsen, Lars Peter, and Mainz, Jan
2005 Errors in the Medication Process: Frequency, Type, and Potential. International Journal for Quality in Health Care 17, 1: 15–22.
Luke, Kang-Kwong, Lam, Tai Pong, and Zhang, Wei
2008 Electronic Medical Record Keeping and Doctor-Patient Interaction: An Analysis of Medical Consultations in Hong Kong. In: It’s the Dragon’s Turn: Chinese Institutional Discourses, Hao Sun and Dániel Z. Kádár (eds), 231–260. Bern & New York: Peter Lang.
Meehan, Albert J
1986 Record-Keeping Practices in the Policing of Juveniles. Urban Life, 15, 1: 70–102.
Ochs, Elinor
1979 Transcription as Theory. In: Developmental Pragmatics, Elinor Ochs and Bambi B. Schieffelin (eds), 43–72. New York: Academic Press.
Reiser, Stanley J
1991 The Clinical record in Medicine. Part 1: Learning from Cases. Annals of Internal Medicine 114, 10: 902–907.
Ruusuvuori, Johanna
2001 Looking Means Listening: Coordinating Displays of Engagement in Doctor–Patient Interaction. Social Science & Medicine 52, 7: 1093–1108.
Sacks, Harvey, Schegloff, Emanuel A. and Jefferson, Gail
1974 A simplest systematics for the organization of turn-taking for conversation. Language 50, 4: 696–735.
Samra-Fredericks, Dalvir
2010 The interactional accomplishment of a strategic plan. In: Organisation, Interaction and Practice. Studies in Ethnomethodology and Conversation Analysis, Nick Llewellyn and Jon Hindmarsh (eds), 198–217. Cambridge: Cambridge University Press.
Sandelowski, Margarete
2000 Devices and Desires: Gender, Technology and American Nursing. Chapel Hill: University of North Carolina Press.
Schegloff, Emanuel A
1992 Repair after next turn: The last structurally provided defense of intersubjectivity in conversation. American Journal of Sociology 97, 5: 1295–1345.
Schegloff, Emanuel A., Jefferson, Gail, and Sacks, Harvey
1977 The Preference for Self-Correction in the Organization of Repair in Conversation. Language 53, 2: 361–382.
Schryer, Catherine F
1993 Records as Genre. Written Communication 10, 2: 200–234.
Stivers, Tanya
2007 Prescribing Under Pressure. Parent-Physician Conversations and Antibiotics. Oxford: Oxford University Press.
Suchman, Lucy
2000 Making a case: ‘knowledge’ and ‘routine’ work in document production. In: Workplace Studies. Recovering Work Practice and Informing System Design, Paul Luff, Jon Hindmarsh and Christian Heath (eds), 29–54. Cambridge: Cambridge University Press.
Wibe, Torunn, Hellesø, Ragnhild, Slaughter, Laura, and Ekstedt, Mirjam
2011 Lay People’s Experiences with Reading their Medical Record. Social Science & Medicine 72, 9: 1570–1573.
Zimmerman, Don H
1974 Facts as a Practical Accomplishment. In: Ethnomethodology, Roy Turner (ed), 128–143. Harmondsworth, Middlesex: Penguin Education.
1998 Identity, Context and Interaction. In: Identities in Talk, Charles Antaki and Sue Widdicombe (eds), 87–106. London: SAGE Publications.
Cited by
Cited by 3 other publications
Izumi, Hiroaki
2019. Use of the functional independence measure in Japanese rehabilitation team interaction.
Discourse Studies 21:6 ► pp. 660 ff. 
Nielsen, Søren Beck
2021. Interactional integration of talk and note-taking.
Psychology of Language and Communication 25:1 ► pp. 145 ff.
Sterponi, Laura, Cristina Zucchermaglio, Francesca Alby & Marilena Fatigante
2017. Endangered Literacies? Affordances of Paper-Based Literacy in Medical Practice and Its Persistence in the Transition to Digital Technology.
Written Communication 34:4 ► pp. 359 ff.
This list is based on CrossRef data as of 22 january 2023. Please note that it may not be complete. Sources presented here have been supplied by the respective publishers. Any errors therein should be reported to them.